Burn Injuries PDF

Burn Injuries DR.SARKAWT S.KAKAI FKHMS(ORTHO. &TRAUMA) Introduction The skin is the largest organ of the body, and the most frequently injured structure in burns. The outer layer, which is typically first to be injured, is called the epidermis. Beneath the epidermis lies the dermis. This layer provi...

Burn Injuries DR.SARKAWT S.KAKAI FKHMS(ORTHO. &TRAUMA) Introduction The skin is the largest organ of the body, and the most frequently injured structure in burns. The outer layer, which is typically first to be injured, is called the epidermis. Beneath the epidermis lies the dermis. This layer provides nutrition and structural support. Elastic fibers allow the skin to tolerate pressure and shearing forces. Functional presentation The depth or thickness of the injury is considered very important. Starting it includes superficial (epidermis), superficial partial (extending into dermis), deep partial (epidermis and most of dermis, with impaired healing and high risk of scarring), and full thickness (not expected to heal). Percentage of total body surface area (TBSA) involved is also critical. The “Rule of 9s” allocates 9% to the head and each upper extremity, 18% to anterior trunk, posterior trunk, and each lower extremity, and 1% to the perineum. Other organ systems may be injured during burns and associated trauma. Respiratory involvement after inhalation of smoke or fumes may be the most critical. Damage to the gastrointestinal tract may hinder the critical process of providing nutritional support to allow healing. Electrical injuries may cause cardiac damage. Nerve injuries are of particular importance. Nerve endings may be damaged in partial thickness burns, causing neuropathic pain while reducing useful sensation. Full thickness injuries destroy nerves, taking away protective sensation. Electrical injuries, burns covering over 15% TBSA, and stays over 20 days in intensive care are associated with a particularly high risk of neuropathy Post-burn management Can span from inception to the hospital to several months or years, depending on the severity of the injury. Stages of rehabilitation can be divided into early and later stages although there is no clear cut time frame for each as they are both thought to overlap. Early stage Also known as wound healing phase. Essentially, the aims of this stage are as follows: Respiratory care. Chest clearance can be achieved by raising the head and chest region. Physiotherapy techniques such as deep breathing exercises, v ibrations, percussion, postural drainage, coughing and suctioning can be employed to clear excess secretions. Prevention of deep vein thrombosis can be achieved by encouraging early ambulation. Prevention of contractures and stiffness Splinting and proper positioning will help achieve this aim. Also performing active or passive range of motion (ROM) exercises, depending on the patient's level of consciousness is crucial in the prevention of these complication. Immobilisation is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an anti-deformity position Edema Edema (accumulation of fluid in soft tissues with swelling) may be significant. Use of elastic dressings, elevation, and mobilization may be employed for edema control. In severe cases involving burns around the circumference of a limb, nerves may be injured and flow through blood vessels may be compromised, even to a degree leading to amputation. Compartment syndrome may require surgical intervention. Pressure garments are commonly used on grafted burns or those that take longer than 14 days to heal. These are intended to reduce hypertrophic (overgrown) scarring, perhaps by reducing rates of blood flow to the scar Splinting is a standard procedure to preserve range of motion or protect a healing wound. Lightweight plastic materials are popular. The clinical challenge is to provide a device that will achieve goals of protecting range of motion and preserving joint function without causing undue discomfort to the patient. Pain Pain management is a critical part of patient care. Patients with poorly Burn Injuries controlled pain will have difficulty complying with the rigors of acute care and rehabilitation. Nerve endings that were painfully stimulated in the initial injury may be further stimulated by inflammatory processes, and by mechanical stresses during wound care and therapies. Resulting pain syndromes can be associated with significant functional and psychological morbidity Location of Burn Contracture Tendency Anti-Contracture Positioning and/or Typical Splint Anterior elbow Flexion Elbow extension splint in 5-10 degrees of flexion Dorsal wrist Wrist extension Wrist support in neutral Volar wrist Wrist flexion Wrist cockup splint in 5-10 degrees of flexion Dorsal hand Claw hand deformity Functional hand splint with MP joints at 70-90 degrees, IP joints fully extended, first web space open, thumb in opposition Volar hand Palmar contracture Cupping of hand Palm extension splint MP’s in slight hyperextension Anterior hip Hip flexion Prone positioning, Weights on thigh in supine Knee immobilizers Knee Knee flexion Knee extension positioning and/or splints Prevent external rotation, which may cause peroneal nerve compression Foot Foot drop Ankle at 90 degrees with foot board or splint Watch for signs of heel ulcers Later Stage This stage, also known as the post-healing stage, focuses more on the following: An improvement in muscle strength, endurance, balance and coordination owing to prolonged bed immobilization. Scar management Ambulation with little or no assistance Engaging in functional activities Integration into society PSYCHOLOGICAL AND VOCATIONAL IMPLICATIONS Recovery from moderate to major burns can be very stressful. Depression and post-traumatic stress disorders (PTSD) are common sequellae. Psychological interventions appear to effectively reduce burn patient psychological morbidities. Psychological interventions significantly reduce the risk of depression, anxiety, and hospital stay compared to usual care. Treatment It is critical to seek emotional support from professionals and other survivors to help with your psychological distress. Get sufficient sleep and eat healthy foods. Avoid tobacco, illicit drugs and/or excessive use of alcohol because they can make matters worse. Medications Depression (e.g., low mood, low energy, irritability towards self and others). Anxiety (e.g., worry, recurring and disturbing memories). Sleep (e.g., nightmares, difficulty relaxing). Developmental disabilities Lec.3 Dr.Sarkawt S.Kakai KHCMS (Ortho. & Trauma) Developmental Disabilities Are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. The prevalence of DDs is increasing. From 1997 to 2008 Autism prevalence increased by 289.5 percent while ADHD prevalence increased by 33 percent. Developmental disabilities (DD) includes conditions such as Attention deficit hyperactivity disorder (ADHD) Autism Intellectual disability Learning difficulties (e.g. developmental coordination disorder (DCD) / dyspraxia, auditory processing disorder) Blindness Cerebral palsy Moderate to profound hearing loss Seizures Causes Genetic or chromosome abnormalities. These cause conditions such as Down syndrome. Prenatal exposure to substances. For example, drinking alcohol when pregnant can cause fetal alcohol spectrum disorders. Certain infections in pregnancy Preterm birth Developmental Milestones Birth to 4 months Includes smiling, and bringing hands to mouth. 6 months. Includes playing with others, sitting without support, and rolling over. 9 months. Includes making sounds like "mama" and "dada," understanding the word "no," crawling, and pulling to a stand. 1 year. Includes playing peekaboo, following simple directions, and walking while holding on to furniture. 18 months. Includes speaking and understanding several words, eating with a spoon, walking, and walking up and down stairs. 2 to 3 years. Includes recognizing labels and colors, naming pictures of common objects, getting dressed and undressed, and walking and running easily. Screening test The American Academy of Pediatrics (AAP) recommends developmental and behavioral screenings for all children during regular well-child checkups at the following ages:9, 18 and 30 months Ages and Stages Questionnaire Parents' Evaluation of Developmental Status Modified Checklist for Autism in Toddlers (M-CHAT) Intellectual disability A term used when there are limits to a person’s ability to learn at an expected level and function in daily life. Levels of intellectual disability vary greatly in children. Children with intellectual disability might have a hard time letting others know their wants and needs, and taking care of themselves. are generally assessed through the use of standardized individually administered IQ tests. Signs sit up, crawl, or walk later than other children learn to talk later, or have trouble speaking find it hard to remember things have trouble understanding social rules have trouble seeing the results of their actions have trouble solving problem Classification Heber (1959, 1961) linked his description of “retardation in measured intelligence” to the following IQ scores: “borderline”(IQ range of 70–84), “mild” (IQ range of 55–69), “moderate” (IQ range of 40– 54), “severe” (IQ range of 25–39), and “profound” (IQ below 25). Definition and Examples of Intensities of Supports Intermittent Supports. Supports on an “as needed basis.” Characterized by episodic nature, person not always needing the support(s). Limited Supports. An intensity of supports characterized by consistency over time, time-limited but not of an intermittent nature Extensive Supports. This is characterized by regular involvement (e.g., daily) Pervasive Supports. This is characterized by their constancy and high intensity, provided across environments, potentially life-sustaining in nature. Attention Deficit Hyperactivity Disorder Is a neurodevelopmental disorder that affects the functioning of the brain. It seems to be due to abnormalities in the dopamine system and a change in frontal lobe development. While its cause is unknown, it is considered a genetic disorder, with environmental factors (e.g. diet, physical and social environments) playing a small role in its etiology. The following factors can increase the risk of ADHD: Very low birth weight Premature birth Exceptional early adversity ADHD is diagnosed based on reported behaviors or psychiatric assessment. The primary symptoms associated with ADHD are inattentiveness, hyperactivity and impulsiveness. However, fine and gross motor skills are affected in around 30 to 50 percent of children with ADHD, particularly in the predominantly inattentive and combined ADHD group. These motor problems are often ignored due to behavior difficulties, but children typically struggle with: Dressing, Handwriting, Learning to ride a bicycle and Tying shoelaces Autism Leo Kanner (1943) described a group of 11 children who displayed a similar pattern of specific symptoms that were significantly different from those of other childhood behavior disorders. Kanner called this form of childhood psychopathology “early infantile autism” Autism Spectrum Disorder (ASD), is a different way of thinking involving a neurological developmental difference that changes the way a person relates to the environment and people around them. A person with autism sees, experiences and understands the world in a different manner Etiology/Epidemiology ASD is a neurobiological disorder influenced by both genetic and environmental factors affecting the developing brain. Currently, no single universal cause has been identified but research is ongoing to discover potential etiologic mechanisms in ASD. ASD (according to some research) is becoming more prevalent. This finding is questioned, possibly be attributed to increased awareness, overdiagnosis, or overinclusive diagnostic criteria. Its prevalence is reported to be 1 in 68. Diagnoses based on combined clinician observation and caregiver reports are consistently more reliable than those based on either observation or reports alone. Later diagnoses often occur in presence of co-occurring problems such as anxiety, hyperactivity, or mood disorders that might have triggered the ASD, along with the same factors that play a part in delayed diagnoses in younger children. There is a need for clinical follow-up and reassessments of children diagnosed with ASDs, especially during the preschool years Diagnosis Hematological disorders Lec.3 DR.SARKAWT S.KAKAI FKHCMS There are many conditions of/or affecting the human hematologic system ie the biological system that includes plasma, platelets, leukocytes, and erythrocytes, the major components of blood and the bone marrow. Hemophilia Hemophilia is the most commonly known hemorrhagic disorder causing bleeding due to defects in the coagulation factors. This leads to delay in the coagulation process post injury. Hemophilia is usually an X linked recessive inherited disease, but in some rare conditions, it has been found to be acquired. Comparison between types of haemophilia Haemophilia A Haemophilia B Haemophilia C Known as Classical / Standard haemophilia Christmas haemophilia Rosenthal’s disease Protein factor affected Factor VIII Factor IX Factor XI Genetic Inheritance X linked recessive X linked recessive Autosomal recessive Gender Affected Mostly males Mostly Males Females & males equally Severity Mild, Moderate and Severe Mild, Moderate and Severe Mild Diagnosis CBC Clotting and bleeding time Clotting Factor Tests Severity Severity Levels of Factor VIII or IX in the blood Normal 50% to 100% Mild haemophilia Greater than 5% but less than 50% Moderate haemophilia 1% to 5% Severe haemophilia Less than 1% Orthopedic manifestations hemophilic arthropathy synovitis cartilage destruction joint deformity intramuscular hematoma (pseudotumor) leg length discrepancy due to epiphyseal overgrowth fractures due to generalized osteopenia compartment syndrome Treatment Thalassemia Thalassemia is one of the most common inherited diseases. It is defined as an autosomal recessive blood disorder. The disease results from a reduction or absence in the production of globin chains that make up the haemoglobin (Hb) leading to abnormal destruction of erythrocytes and consequently decreased oxygen delivery There are two types of Thalassaemia: α- and β- depending on the type of the involved globin chain. Clinically, Thalassemia is classified into three forms: Thalassemia major: this is a severe form of anaemia where patients need continuous blood transfusions throughout their lives. Thalassemia intermedia: mild to moderate anaemia, patients occasionally need blood transfusions Thalassemia minor or trait: patients have mild symptoms and they usually don’t need blood transfusions. Diagnosis The Red Blood Cells (RBC) count specifically the number of erythrocytes. Genetic testing, haemoglobin electrophoresis and reticulocyte count Treatment Fracture Vertebral anomaly Orthopedic Manifestations Fatigue Osteoporosis Avascular necrosis Leukemia Is a cancer of the early blood-forming cells. There are several types of leukemia, which are divided based mainly on whether the leukemia is acute (fast growing) or chronic (slower growing), and whether it starts in myeloid cells or lymphoid cells Leukemia is hundreds of different diseases on a molecular level, with no two leukemias being exactly alike Pathophysiology Bone marrow is responsible for the making of red blood cells (RBC), white blood cells (WBC) and platelets. In leukaemia, due to the immature cells or some defect in the cells of the bone marrow, the abnormal and functionless WBC are produced which are unable to fight against the infection and defend the body against foreign substances. Also, they obstruct the production of other blood cells by dividing quickly and crowding among normal cells. Diagnosis Treatment Orthopedic Manifestations Osteopenia Lytic lesions, Periosteal new bone, and sclerotic lesions Metaphyseal bands, Avascular necrosis